Jose B.

Lingad Memorial General Hospital

Department of General Surgery

Thermal Skin Acute

Injuries Grafts Abdomen

Adopted from the lecture of Dr. Andrew Jay Pusung

Objectives :

Determine the type of burn injuries

Classify the depth of the burn based on the manifestation
presented.
Determine the extent of the burn injury by calculating the
TBSA involved.
Perform the correct sequence in assessing and resuscitating
a burn patient.
Know the surgical management of burns.
Identification and Management of
associated injuries
Hemodynamic Normality
 Case Scenario

BA 54/M
Rescued from a smoke-filled room in a burning house.
Patient is conscious, agitated, and coughing carbonaceous
sputum.
His head and upper body appear to be extensively burned.
Thermal Injuries

Burn Injuries Cold Injuries

Burn Injuries

Flame Scalding Contact Chemical Electric

Burn Pathophysiology
What should be our priority?
Stop the burning process!
 Primary Survey!
Case Scenario
A 54-year-old male is rescued A
from a smoke-filled room in a
burning house.
Patient is conscious, agitated, and B
coughing carbonaceous sputum.
His head and upper body appear
to be extensively burned. C

E
Priorities
Manage Airway and Breathing

• Consider inhalation injury.

• Establish and maintain patent airway early
and consider early ET intubation.
• Oxygenation and ventilation.
• Obtain ABGs and CO levels.
Assessment and Management
How do I identify inhalation injury?

• History of closed space

• Singeing of hair, eyebrows,
eyelashes
• Hoarseness and stridor
• Inflamed oropharynx
• Carbonaceous sputum
• Hypoxia
• Carboxyhemoglobin (HbCO) > 10%
American Burn Life Support (ABLS) indications
for early intubation include:

•• Signs of airway obstruction

•• Extent of the burn
•• Extensive and deep facial burns
•• Burns inside the mouth
•• Significant edema or risk for edema
•• Difficulty swallowing
•• Signs of respiratory compromise
•• Decreased level of consciousness where airway protective reflexes are
impaired
•• Anticipated patient transfer of large burn with airway issue without qualified
personnel to intubate en route
CO levels and symptoms

CO less than 20% in the body usually have no physical symptoms.

Higher CO levels can result in:

•• headache and nausea (20%–30%)
•• confusion (30%–40%)
•• coma (40%–60%)
•• death (>60%)

Cherry-red skin- is rare - may only be seen in moribund patients.

Assessment and Management
Maintain Organ Perfusion
• Adequate venous access
• Monitor vital signs
• Hourly urine output
• Adult: 0.5 – 1.0 mL / kg / hour
• Child: 1.0 mL / kg / hour
Assessment and Management
How do I estimate burn size and depth?
Assessment and Management
How do I estimate burn size and depth?

Wallace Burn Chart

(Rule of Nines)
Superficial burns

e.g., sunburn

characterized by erythema and pain

does not blister because the epidermis

remains intact.

generally do not require intravenous fluid

replacement

not included in the assessment of burn size.

Partial-thickness burns

Superficial partial-thickness burns

moist, painfully hypersensitive (even to

air current), potentially blistered,
homogenously pink, and blanch to touch

Deep partial-thickness burns

drier, less painful, potentially blistered,

red or mottled in appearance, and do not
blanch to touch
Full-thickness burns

appear leathery

skin may appear translucent or waxy white.

painless to light touch or pinprick and

generally dry

the underlying dermis may be red initially,

but it does not blanch with pressure

the deeper the burn, the less pliable and

elastic it becomes; therefore these areas may
appear to be less swollen
Assessment and Management

What is the rate and type of fluids

administered to patients with burns?
The current consensus guidelines: fluid resuscitation
should begin at 2 ml of lactated Ringer’s x patient’s
body weight in kg x % TBSA for
second- and third-degree burns.

Resuscitation of pediatric burn patients should begin at

3 mL/kg/% TBSA.

ATLS 10th Edition

ATLS 10th Edition
Assessment and Management
What is the rate and type of fluids
administered to patients with burns?
• 2 mL warmed Ringer’s lactate x wt (kg) x total
BSA (whole number, e.g., 40 not 0.4) in first 24
hours

• Administer ½ calculated fluids volume in first 8

hours

• Administer the remainder during next 16 hours

• Monitor urinary output

It is important to understand that formulas provide a
starting target rate; subsequently, the amount of fluids
provided should be adjusted based on a urine output target
of 0.5 mL/kg/hr for adults and 1 mL/kg/hr for children
weighing less than 30 kg.

In adults, urine output should be maintained between 30

and 50 cc/ hr to minimize potential over-resuscitation.

Calculated fluid rate is only an estimate.

ATLS 10th Edition

In adults, urine output should be maintained between 30
and 50 cc/ hr to minimize potential over-resuscitation.

SAMPLE COMPUTATION:
• 60kg adult
• Superficial Partial Thickness burn
• 35% TBSA

• 60kg x 2ml of Ringer’s Lactate x 35 = 4200mL

Calculated fluid rate is only an estimate.

ATLS 10th Edition

Assessment and Management
Other Information
• Secondary Assessment (AMPLE history)
• Tetanus status

Other Management
• Baseline blood analyses and chest x-ray
• Gastric tube insertion
• Analgesia – intravenous narcotics
• Wound care
• Documentation
Assessment and Management

Management of Chemical Burns

• Brush off powder
before flushing
• Flush with copious
amounts of water for
20 – 30 minutes
• Alkali burns are
generally more serious
than acid burns.
Assessment and Management

Management of Electrical Burns

• Fascia and muscle
damage; may spare
overlying skin
• Myoglobinuria:
Increase fluids
• Maintain adequate
perfusion
Surgical Management of Burns
Current therapy of the acutely burned patient is
based on the following key points

Adequate Resuscitation

Early wound debridement and closure

Support of post burn hypermetabolic

response

Control of infection - excising the eschar and

covering the wound as early as possible
Need for surgical intervention/debridement
depends on the depth of the injury.

Full-thickness burns (all of the dermal

elements) - no epidermal cells left to
regenerate the injured area.

Partial thickness injuries allow epidermal

cells to survive in the dermal elements to
repopulate the injured area
Complete debridement should proceed at the
earliest possible time

If donor sites are insufficient to provide total

wound coverage, biological dressings
(preferably cadaveric donor allograft) should
be used to cover the remaining wounds.

Excision of burn wounds requires large

volumes of blood for transfusion
(approximately 1 cc/cm2)
Minimizing blood loss during
debridement:
Use of excision to the level of fascia.

Use of tourniquets when performing tangential

excisions of the extremities.

Adrenaline-lidocaine subcutaneous infiltration

solutions can be used in both burned areas and donor
sites

Thrombin spray, fibrin glue, alginate dressings

Topically applied adrenaline gauzes

P. Gacto-Sanchez
Escharotomy
When the burn eschar circumferentially
surrounds any body structure

Releases the constricting tissue

Performed on both sides of the torso or the

medial and lateral sides of each affected limb.
Escharotomy

For the abdomen and chest,

transverse incisions are often
required to permit restoration
of respiratory movement.

Delayed primary closure of

escharotomy incisions may
produce better functional and
cosmetic results.
Skin Grafts
The standard for rapid and permanent
closure of full thickness burns is a split-
thickness skin graft from an uninjured donor
site on the same patient.

Sheet Grafts

Meshed Grafts
Skin Grafts
Sheet graft

Size of the donor skin is about the same as

the burn wounds.

Donor skin used in sheet grafts does not

usually stretch

Sheet grafts are usually saved for the face,

neck and hands
Sheet graft

The disadvantages of sheet grafts comprise

both higher rates of postoperative
hematoma and larger donor site than
meshed skin.

Sheet grafts are usually more durable and

scars less.
Meshed skin grafts.

Split-thickness skin grafts can be meshed with

variable expansion ratios to increase the coverage
area.

Common mesh ratios include 1:1, 1.5:1, 2:1, 3:1, and

4:1. The larger the ratio, the less the wound is actually
covered and the more hypertrophic scarring results
during the slow process of epithelial cell migration.
Meshed Skin Grafts

Meshing allows blood and body fluids to drain from

under the skin grafts

Meshing has poor outcome on range of motion and

the graft site healing rate resulting in less satisfactory
functional and cosmetic result.
Temporary Wound Coverage
Patients with more extensive burns often require
temporary coverage with an allograft, xenograft, skin
substitute, or dermal analog due to insufficient or
unavailable donor sites.

Gold standard for temporary skin substitute is

cadaver allograft
Skin
Substitutes
-
Epidermal
substitutes are
normally only a few
cell layers thick and
lack normal dermal
components.

-
Collagen-based
dermal substitutes
are porous matrices
that act as
templates for
dermal
regeneration P. Gacto-Sanchez
P. Gacto-Sanchez
Flap Solution
On mobile areas such as joints, neck, and axilla, skin-
grafted wounds can contract, leading to secondary
contractures.

Local flaps provide an excellent choice to supply

stable coverage and minimize joint contractures.

Classified as advancement flaps, rotation flaps, and

transposition flaps.
Pain Management

Persistent pain of a peripheral origin may

induce pathological changes on a spinal and
supraspinal level, leading to central
sensitization, mechanical and thermal skin
hyperalgesia and pain maintenance.

Patient-controlled analgesia (PCA) is used for

patients upon hospital admission and after
surgical procedures.
Pain Management
Sedation with propofol or midazolam is used very
frequently for extensive burn-dressing changes.

Fentanyl administered during treatments and

procedures has shown a significant difference in pain
reduction post-procedure

Ketamine may be used for conscious sedation during

dressing changes in burn patients
Pressure Garments
Custom-fit pressure garments have been used in burn
patients in order to prevent or correct hypertrophic
scarring.

Wounds treated with tighter compression to be

thinner, softer, and show a better overall appearance.

Benefits were most evident in patients with moderate-

to-severe scarring.
Physiotherapy
An integral component of burn care.

order to maintain the range of motion

prevent contracture development,

maximize function

promote psychological wellbeing and

social integration.
Transfer Criteria
Who do I transfer to a burn center?

Partial-thickness and Full-thickness Burns

• > 10% BSA

• Any size burn affecting:
• Face • Hands • Perineum
• Eyes • Feet • Skin over
• Ears • Genitalia major joints

• All full-thickness burns (all ages)

Transfer Criteria
Who do I transfer to a burn center?
Partial-thickness and Full-thickness Burns
• Significant electrical burns, including lightning
injuries
• Significant chemical burns
• Inhalation injury
• Patients with preexisting illnesses that could
complicate treatment or recovery
• Associated injuries may need care in a trauma center
before transfer to a burn center
Summary
Burn Injuries
Recognize and treat associated life
threatening injuries.
Appropriate fluid resuscitation
Early identification of burn injuries requiring
transfer
Early wound debridement and wound
coverage to prevent infection
Burn rehabilitation to provide functional and
good aesthetic outcome.
?
ACUTE ABDOMEN

Adopted from the lecture of Dr. Andrew Jay Pusung

Definitions:
ACUTE ABDOMEN ACUTE SURGICAL
ABDOMEN
Any serious acute
intraabdominal An acute abdomen
condition that is that requires
attended by pain, emergency
tenderness and surgical
rigidity and for intervention.
which emergency
surgery may be
considered.
ACUTE ABDOMEN
• Most common cause of surgical emergency admission

• Encompass various conditions ranging from the trivial to the

life-threatening

• Clinical course can vary from minutes to hours, to weeks

• It can be an acute exacerbation of a chronic problem e.g.

Chronic Pancreatitis, Vascular Insufficiency
Assessment
Diagnosis can be made most of the time by a
good history and a proper physical
examination.

The primary symptom of

the "acute abdomen" is –
Abdominal pain.
Visceral Pain
Due to stretching of fibers innervating the walls
of hollow or solid organ
Inflammation or ischemia stimulating the
receptor neurons
Direct involvement of sensory nerves (e.g.,
malignant infiltration)

It occurs early, dull, poorly localized and

protracted.
Parietal Pain
Mediated by both C and A-delta nerve fibers
A-Delta Nerve Fibers: Responsible for the
transmission of more acute, sharper, better-
localized pain sensation.

Direct irritation of the somatically innervated

parietal peritoneum by pus, bile, urine, or
gastrointestinal secretions leads to more
precisely localized pain

It occurs late and better localized

Referred Pain
Pain is felt at a site away from the
pathological organ.

Pain is usually ipsilateral to the involved

organ (midline if pathology is midline)
Referred Pain
Historical features of abdominal pain
Location, quality, severity, onset, and
duration of pain, aggravating and alleviating
factors

GI symptoms/ GU symptoms

Vascular symptoms (A. fib / AMI / AAA)

Historical features of abdominal pain
PMH
Recent / current medications

Past hospitalizations/ surgeries

Chronic disease

Social history (Alcohol/ drugs/ tobacco/ psychosocial

stress)

Occupation/ Toxic exposure (CO / lead)

Other Relevant Aspects of the History
Gynecologic History

Menstrual history is crucial to the diagnosis

of ectopic pregnancy, mittelschmerz, and
endometriosis.

History of vaginal discharge or

dysmenorrhea may denote pelvic
inflammatory disease.
Character of pain
Sharp superficial constant pain - perforated
ulcer or a ruptured appendix, ovarian cyst,
or ectopic pregnancy

The gripping, mounting pain of small bowel

obstruction (and occasionally early
pancreatitis) is usually intermittent, vague,
deep-seated, and crescendo at first but soon
becomes sharper, unremitting, and better
localized
Character of pain
Pain caused by lesions occluding smaller
conduits (bile ducts, uterine tubes, and
ureters) rapidly becomes unbearably intense

Colic if there are pain-free intervals that

reflect intermittent smooth muscle
contractions, as in ureteral colic.
Other Symptoms Associated with
Abdominal Pain
Vomiting

stimulated by secondary visceral afferent fibers, the

medullary vomiting centers activate efferent fibers
to induce reflex vomiting.

Hence, pain in the acute surgical abdomen usually

precedes vomiting, whereas the reverse holds true
in medical conditions.

the onset and character of vomiting may indicate

the level of the lesion.
Other Symptoms Associated with
Abdominal Pain
Constipation
Reflex ileus is often induced by visceral afferent fibers
stimulating efferent fibers of the sympathetic autonomic
nervous system (splanchnic nerves) to reduce intestinal
peristalsis.

Paralytic ileus undermines the value of constipation in the

differential diagnosis of an acute abdomen.

Constipation itself is hardly an absolute indicator of

intestinal obstruction.
Other Symptoms Associated with
Abdominal Pain
Obstipation

Severe form of constipation

Absence of passage of stool and flatus

May denote intestinal obstruction

Other Symptoms Associated with
Abdominal Pain
Diarrhea

Copious watery diarrhea is characteristic of

gastroenteritis and other medical causes of an acute
abdomen.

Blood-stained diarrhea suggests ulcerative colitis,

Crohns disease, or bacillary or amebic dysentery.

It is also common with ischemic colitis but often

absent in intestinal infarction due to superior
mesenteric artery occlusion.
Other Specific Symptoms
• Jaundice suggests hepatobiliary disorders.

• Hematochezia or Hematemesis, a
gastroduodenal lesion or Mallory-Weiss
syndrome.

• Hematuria, ureteral colic or cystitis.

• The passage of blood clots or necrotic

mucosal debris may be the sole evidence of
advanced intestinal ischemia.
Physical Examination of the
Abdomen
Note pt’s general appearance. Realize that
the intensity of the abdominal pain may have
no relationship to severity of illness.

One of the initial steps of the PE should be

obtaining and interpreting the vitals.

Pts with visceral pain are unable to lie still.

Pts with peritonitis like to stay immobile.

Physical Examination of the
Abdomen
INSPECT for distention, scars, masses, rash.

AUSCULATE for hyperactive, obstructive,

absent, or normal bowel sounds.

PALPATION to look for guarding, rigidity,

rebound tenderness, organomegaly, or hernias.

Women should have pelvic exam (check FHR if

pregnant). •

PERCUSSION for dullness or tympany

Physical Examination of the
Abdomen
Inspection:

The abdomen should be thoughtfully inspected

before palpation.

A tensely distended abdomen with an old surgical

scar suggests both the presence and the cause
(adhesions) of small bowel obstruction.

A scaphoid contracted abdomen is seen with

perforated ulcer. visible peristalsis occurs in thin
patients with advanced bowel obstruction.
Physical Examination of the
Abdomen
Auscultation:

Auscultation of the abdomen should also precede

palpation.

Peristaltic rushes synchronous with colic are heard in mid

small bowel obstruction and in early acute pancreatitis.

High-pitched hyperperistaltic sounds unrelated to the

crampy pain is characteristic of gastroenteritis, dysentery,
and fulminant ulcerative colitis.

An abdomen that is silent except for infrequent tinkly or

squeaky sounds may denote bowel ischemia.
Physical Examination of the
Abdomen
Coughing to elicit pain:

The patient should be asked to cough and point to

the area of maximal pain.

Peritoneal irritation so demonstrated may be

confirmed afterward without causing unnecessary
pain by rigorous testing for rebound tenderness.

Unlike the parietal pain of peritonitis, colic in

visceral pain is seldom aggravated by deep
inspiration or coughing.
Physical
Examination
Patient on back, knee
bent (if possible)

Warm hands

Palpate each quadrant

Work toward area of

pain

Note tenderness,
rigidity, guarding,
masses
Palpation:

Guarding is assessed by placing both hands

over the abdominal muscles and depressing
the fingers gently. If there is voluntary
spasm, the muscle will be felt to relax when
the patient inhales deeply through the
mouth. With true involuntary spasm,
however, the muscle will remain taut and
rigid ("boardlike") throughout respiration.
Tenderness that connotes localized peritoneal
inflammation is the most important finding
in patients with an acute abdomen.

Its extent and severity are determined first

by one- or two-finger palpation, beginning
away from the area of cough tenderness and
gradually advancing toward it.

Tenderness is usually well demarcated in

acute cholecystitis, appendicitis,
diverticulitis, and acute salpingitis.
If there is poorly localized tenderness
unaccompanied by guarding, one should
suspect gastroenteritis or some other
inflammatory intestinal process without
peritonitis.

Compared with the degree of pain,

unexpectedly little and only vague
tenderness is elicited in uncomplicated
hollow viscus obstruction, walled-off or
deep-seated perforations (e.g., retrocecal or
retroileal appendicitis)
Physical Examination of the
Abdomen
Percussion:

Percussion serves several purposes.

Tenderness on percussion is akin to eliciting rebound

tenderness; both reflect peritoneal irritation and
parietal pain.

With a perforated viscus, free air accumulating under

the diaphragm may efface normal liver dullness.

Tympany near the midline in a distended abdomen

denotes air trapped within distended bowel loops.
Investigative Studies
The history and physical examination by themselves
provide the diagnosis in two thirds of cases of an
acute abdomen.

Supplementary laboratory and radiologic

examinations are indispensable for diagnosis of many
surgical conditions, for exclusion of medical causes
ordinarily not treated by operation, and for assistance
in preoperative preparation.

Test results must always be interpreted within the

clinical context of each case.
Blood Studies: Hemoglobin, hematocrit, and white
blood cell and differential counts taken on admission are
highly informative.

Only a rising or marked leukocytosis (> 13,000/L),

especially in the presence of a shift to the left on the
blood smear, is indicative of serious infection.

Moderate leukocytosis, commonly encountered in

medical as well as surgical inflammatory conditions, is
nonspecific and may be even absent in elderly or
debilitated patients with infections.
A specimen of clotted blood for crossmatching
should be sent whenever urgent surgery is
anticipated.

Serum electrolytes, urea nitrogen, and creatinine

are important, if hypovolemia is expected
(i.e., due to shock, copious vomiting or
diarrhea, tense abdominal distention, or
delay of several days after onset of
symptoms).
Arterial blood gas determinations should be obtained in
patients with hypotension, generalized peritonitis,
pancreatitis, possible ischemic bowel, and septicemia.
Unsuspected metabolic acidosis may be the first clue
to serious disease. o serum amylase :

Serum amylase level corroborates a clinical diagnosis

of acute pancreatitis. • Moderately elevated values
must be interpreted with caution, since abnormal
levels frequently accompany strangulated or ischemic
bowel, twisted ovarian cyst, or perforated ulcer.
Liver function tests (serum bilirubin, ALP,
AST, ALT, albumin, and globulin.are useful
to differentiate medical from surgical hepatic
disorders and to gauge the severity of
underlying parenchymal disease.

Clotting studies (platelet counts, prothrombin

time, and partial thromboplastin time) and a
peripheral blood smear may be requested if
the history hints at a possible hematologic
abnormality (cirrhosis, petechiae, etc).
Urine Tests

Dark urine or a raised specific gravity

reflects mild dehydration in patients with
normal renal function.

Hyperbilirubinemia may give rise to

teacolored urine that froths when shaken.
•

Microscopic hematuria or pyuria can

confirm ureteral colic or urinary tract
infection.
Urine Tests

Dipstick testing (for albumin, bilirubin,

glucose, and ketones) may reveal a medical
cause of an acute abdomen.

Pregnancy tests should be ordered if there

is a history of a missed period.
Stool Tests

Occult fecal blood : • positive test points to

a mucosal lesion that may be responsible
for large bowel obstruction or chronic
anemia, or it may reflect an unsuspected
carcinoma.

Warm stool smears :for bacteria, ova, and

animal parasites may demonstrate amebic
trophozoites in patients with bloody or
mucous diarrhea
Plain Chest X-Ray Studies :

An erect chest x-ray is essential in all cases

of an acute abdomen. it is vital for
preoperative assessment, but it may also
demonstrate supradiaphragmatic
conditions that simulate an acute abdomen
(e.g., lower lobe pneumonia or ruptured
esophagus).

An elevated hemidiaphragm or pleural

effusion may direct attention to subphrenic
inflammatory lesions.
Plain Abdominal X-Ray Studies:

Plain supine films of the abdomen should be obtained

only selectively. erect (or lateral decubitus) views
contribute little additional information except in
suspected intestinal obstruction.

Plain films are helpful in patients with possible

intestinal obstruction or ischemia, perforated viscus,
renal or ureteral calculi, or acute cholecystitis.

They are seldom of value in patients suspected to

have appendicitis or urinary tract infection.
An abnormal bowel gas pattern suggests
paralytic ileus, mechanical bowel
obstruction, or pseudoobstruction.

A diffuse gas pattern with air outlining the

rectal ampulla suggests paralytic ileus,
especially if bowel sounds are absent.

Gaseous distention is the rule in bowel

obstruction.
Air-fluid levels are usually seen in distal small
bowel obstruction and a distended cecum with
small bowel dilation in large bowel obstruction.

Adynamic ileus associated with longstanding

acute appendicitis or with an atypical appendix
location often produces a pattern that suggests
localized right lower quadrant ileus.

"Thumbprint" impressions on the colonic wall

are noted in about half of patients with ischemic
colitis.
Biliary tree air designates a biliary-enteric
communication, such as a spontaneous or
surgically created choledochoduodenal
fistula or gallstone ileus.

Air between loops of small bowel may arise

from a small localized perforation.
Obliteration of the psoas muscle margins or
enlargement of the kidney shadows indicates
retroperitoneal disease.

Radiopaque densities of characteristic

appearance and location may confirm a
clinical suspicion of biliary, renal staghorn,
or ureteral calculi; appendicitis; or aortic
aneurysm.
Contrast Radiologic Studies
Not requested routinely or be regarded as screening
studies.

For suspected perforations of the esophagus or

gastroduodenal area without pneumoperitoneum, a
water-soluble contrast medium (eg, meglumine
diatrizoate [Gastrografin]) is preferred.

If there is no clinical evidence of bowel perforation, a

barium enema may identify the level of a large bowel
obstruction or even reduce a sigmoid volvulus or
intussusception.
Ultrasonography
Is useful in evaluating upper abdominal pain
that does not resemble ulcer pain or bowel
obstruction and in investigating abdominal
masses.

Has a diagnostic sensitivity of about 80% for

acute appendicitis and is most useful in
pregnant patients and those presenting with
features suggestive of atypical appendicitis
or in young women with midabdominal or
lower abdominal pain.
Computed Tomography
Urgent or emergent CT scan of the abdomen
is now generally routinely and rapidly
available.

Extremely useful in the evaluation of

abdominal complaints for patients who do
not already have clear indications for
laparotomy or laparoscopy. CT is helpful in
identifying small amounts of free
intraperitoneal gas and sites of inflammatory
diseases that may prompt (appendicitis,
tubo-ovarian abscess) or postpone
Computed Tomography
CT is helpful in identifying small amounts of
free intraperitoneal gas and sites of
inflammatory diseases that may prompt
(appendicitis, tubo-ovarian abscess) or
postpone (diverticulitis, pancreatitis, hepatic
abscess) operation.

It should not replace or delay operation in a

patient for whom the scan will not change
the decision to operate
Laparoscopy
A therapeutic as well as a diagnostic
modality.

In young women, it may distinguish a

nonsurgical problem (ruptured graafian
follicle, pelvic inflammatory disease,
tuboovarian disease) from appendicitis.
Laparoscopy
In obtunded, elderly, or critically ill patients,
who often have deceptive manifestations of
an acute abdomen, it may facilitate earlier
treatment in those with positive findings
while eliminating the added morbidity of a
laparotomy in negative cases.

Where appendicitis is confirmed,

laparoscopic appendectomy may be
performed.
Indications for Urgent Operation in Patients with
an Acute Abdomen.
Physical findings

Involuntary guarding or rigidity, especially if

spreading.

Increasing or severe localized tenderness.

Tense or progressive distention.

Tender abdominal or rectal mass with high

fever or hypotension.

Rectal bleeding with shock or acidosis.

Indications for Urgent Operation in Patients with
an Acute Abdomen.

Equivocal abdominal findings along with

septicemia

Bleeding (unexplained shock or acidosis,

falling hematocrit).

Suspected bowel ischemia (acidosis, fever,

tachycardia).

Deterioration on conservative treatment

Preoperative Management
Resuscitation of acutely ill patients should proceed
based on their intravascular fluid deficits and
systemic diseases.

After initial assessment, parenteral analgesics for pain

relief should not be withheld.

In moderate doses, analgesics neither obscure useful

physical findings nor mask their subsequent
development.

Antibiotics started when indicated.

Preoperative Management
Abdominal masses may become obvious once rectus
spasm is relieved with pain control.

Pain that persists in spite of adequate doses of

narcotics suggests a serious condition often requiring
operative correction.

Medications should be restricted to only essential

requirements. Particular care should be given to use
of cardiac drugs and corticosteroids and to control of
diabetes.
A nasogastric tube should be inserted in patients likely
to undergo surgery when indicated - those with
hematemesis or copious vomiting, suspected bowel
obstruction, or severe paralytic ileus.

A urinary catheter should be placed in patients with

systemic hypoperfusion. In some elderly patients, it
eliminates the cause of pain (acute bladder distention)
or unmasks relevant abdominal signs.

Informed consent for surgery may be difficult to

obtain when the diagnosis is uncertain. It is prudent
to discuss with the patient and family the possibility
of multiple-staged surgeries.
“Please correlate findings
clinically”
Radiologist